# Type 2 Diabetes
-- Last A1c *** on *** - at goal? *** (Goal A1c <7% or <8-8.5% if significant comorbidities or life expectancy <10 years; if <6.5% can back off on some treatments)
-- Issues with regimen: *** (compliance, access, side-effects)
-- Complications: *** (neuropathy, retinopathy, LE ulcers, CKD, gastroparesis)
-- Co-morbidities: *** (HTN, HF, HLD, CKD, Obesity, smoking)
-- Weight/Nutrition/Exercise: *** goal >5% weight loss if BMI >25; aerobic exercise >3 days/week; cut back on refined sugars and grains
-- Oral Agents: *** metformin if A1c >6.5%, next agent if ASCVD high, A1c target not met, or A1c >8.5% at diagnosis
-- Insulin: *** If A1c >9% or on two agents and A1c >8%
-- Lipids: *** (mod-intensity statin age 40-75 - atorva 10-20, rosuva 5-10, simva 20-40, prava 40-80, lova 40; high-intensity if CVD, risk factors, LDL>190, ASCVD >20% - atova 40-80, rosuva 20-40)
-- Co-Morbidity Tx: *** (ACE/ARB for HTN goal <140/90 or CKD with proteinuria or GFR <60)
-- Neuropathy: *** amitriptyline 10-150mg qhs, pregabalin (Lyrica) 150-300mg BID, gabapentin (Neurontin) 300mg-1200mg TID, duloxetine (Cymbalta) 60-120mg daily, venlafaxine 150-225mg; can also trial lidocaine patch or capsaicin cream
-- Screening: *** Foot exam, Annual Vision Exam (q2-3 if normal)
-- Monitoring: *** A1c q6 if controlled, q3 if not controlled; annual BMP and urine albumin/creatinine ratio
-- Refer: for ABI/vascular if concern for PVD; Renal if GFR <30
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Your A1c (a measure of your 3 month sugar average) puts you in the borderline diabetes range, or what we call "prediabetes." A "normal" a1c is 5.6% or less, prediabetes is 5.7 to 6.4%, and diabetes starts at 6.5%. This means that you are at increased risk for developing diabetes.
You can prevent diabetes by cutting calories, especially from sweets, starches (pastas, white rice, potatoes, bread), and sweetened beverages (sodas and juices); getting more exercise (20-30 minutes 3-4 times per week at least); and losing a few pounds.
We should plan to repear your A1c in *** months.
Diabetic Foot Recommendations
We would like you to perform daily foot examinations to assess for any ulcers (including between your toes) and any notable loss of sensation.
Please inspect daily, wash and dry daily, moisterize daily, wear loose fitting socks, trim nails straight across, never go barefoot, avoid high heels and open toed shoes, look inside shoes before putting them on.
Type 2 Diabetes is a complex metabolic syndrome caused by chronically elevated blood glucose levels. Over time, diabetes can lead to damage to the vasculature via nonenzymatic glycation which can lead to retinopathy, CKD, PAD, and heart disease. Diagnose prediabetes when A1c is 5.7-6.4% and diabetes when the A1c is 6.5% or greater. Begin by promoting lifestyle changes including cutting back on sugary drinks like sodas and juices. If prediabetes or just over 6.5%, give the patient 6 months to see if lifestyle changes can bring their levels down. If not, get baseline BMP (creatinine) and urine albumin/creatinine ratio and start the patient on metformin or a GLP-1 agonist. The ACCORD trial showed that targeting A1c 7-7.9 in those with co-morbidities was better than A1c goal <6. However, in otherwise younger or healthier patients, the goal should be to reverse diabetes and get A1c to normal levels. If A1c target not met, or is >8.5% at diagnosis at a second agent, commonly SGLT2 inhibitors, GLP-1 agonists. If A1c >9% on diagnosis, or on two agents with A1c >8%, you should start on insulin. Start with basal insulin, then add prandial one meal at a time with goal AM glucose 80-130 and 1-2 hour post-prandial glucose <180. All patients with diabetes get a statin, with intensity based on risk factors. ACE/ARB is first line for HTN and CKD in patients with diabetes. Patients should also be screened via frequent foot exams and q2-3 year vision exams.